RE: Third Party Administrator's

[David Blasi]

We have interpreted this to mean that if the transaction in question satisfies the definition in the rules it must be standard.  The situations where a plan sponsor of a self-funded plan would be sending a transaction to a TPA that satisfies any of the definitions may not be frequent, but I would assume HHS had to put in this limiting language in case there is some unique arrangement or hybrid type entity.  For example:   837 = ..transmission of a request to obtain payment and the necessary accompanying information from a health care provider to a health plan...   (Unless you are submitting claims as a health care provider to your own plan, transactions between you as a health plan and your TPA to request claims payment would not have to be in this format.  A good example is that the health plan or TPA sending a request to price a claim to a PPO Network would not have to be in the standard format)   278 = A request to review health care to obtain authorization for the health care...a response to the request... (More broad and not limited to transactions between certain covered entities, but will a health plan ever request authorization for health care from a TPA?  Don't think so.  However, if it does, it would have to be standard.)   276/277 = An inquiry to determine the status of a health care claim..a response... (This is the one that may come into play, depending on your need as a health plan to request claims status electronically.  You may also obtain this information via other methods, DDE or WEB, telephone, written requests, but if electronically submitted, it would probably have to be standard.)        Depending on your contractual arrangements, either the health plan or the business associate will need the capability to conduct a standard transaction.  Whether you will use the standard in your own submissions will depend on the specific definition for each transaction.   >>> [EMAIL PROTECTED] 10/17/01 08:21AM >>> Jim, I agree with you.  However, there is somewhat contradictory advice coming out of the FAQs on the employer/TPA question.  Compare the two FAQs cited below.  The first FAQ says exactly what you said.  The second includes the following sentence:  "This means that in cases where the health plan would be required to use a standard transaction within itself, the transaction would have to be standard when conducted between the health plan and its TPA." I can't explain this last sentence.  Any help? http://aspe.os.dhhs.gov/admnsimp/q0041.htm http://aspe.os.dhhs.gov/admnsimp/q0162.htm Kathy Bakich The Segal Company Washington DC -----Original Message----- From: Jim Moynihan [mailto:[EMAIL PROTECTED]] Sent: Tuesday, October 16, 2001 6:52 PM To: [EMAIL PROTECTED] Subject: RE: Third Party Administrator's Hi Cindy: 1) It will be interesting to hear the responses of others to this first question. As an employer you are not a covered entity with regard to HIPAA and Workers Compensation "plans" are not qualified health plans and not covered by HIPAA. Given this scenario you might have a problem obtaining HIPAA language in your contracts. 2) If you are self-insured your TPA must support HIPAA transactions or your plan may be subject to fines. This is a "business associate" relationship. Most of the transactions they will have to support connect them to providers for EDI claims processing. As an employer you might want to communicate with the TPA via the enrollment standard (834) but you do not have to use it as an employer. The 834 contains many features not in the HIPAA Implementation Guides to connect your organization to many different benefit administrators. Are you thinking of any other information exchanges between you and the TPA? These would include stop loss premiums, claims funding and payment, stop loss claims submission and payment, etc. There was a Medical Stop Loss Work Group for 2 years at x12 that adapted the standards for employers, TPAs and Stop Loss Carriers but much of that work did not make it into the HIPAA Implementation Guidelines. Marcia McLure and I co-chaired that committee which did its work in the mid-nineties. Few TPAs were willing to step up to the plate at that time. Nonetheless the standards were changed to do what needs to be done should you wish to adopt them. Good luck. Jim Moynihan McLure-Moynihan, Inc. 28720 Canwood Street Suite 208 Agoura Hills, CA. 91301 -----Original Message----- From: Cindy Nielsen [mailto:[EMAIL PROTECTED]] Sent: Tuesday, October 16, 2001 1:40 PM To: [EMAIL PROTECTED] Subject: Third Party Administrator's As a provider of LTC, we fall under the "covered entity" description in the HIPAA regs.  Obviously we have to be compliant with the Transactions Standards for 837's and 835's, but I am uncertain about the below two scenerios that deal with employee comp claims and benefits plans. 1. Some of our centers have TPA's that handle our workmens' comp claims. Are we required to have something in our contract with them that references HIPAA compliant verbiage. ( This more than likely deals more with the privacy regulation).  2.  We are self-insured but contract with a TPA to administer our employee benefits program.  Does our contract with them need to reference HIPAA verbiage?  When we transmit info to and from our TPA that contain this benefit info do we need to transmit it the appropriate ANSI X12 format or do the Transaction Standards not apply in this situation? Any assistance you can provide would be helpful. Cindy M. 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